ODASL
OKLAHOMA DETERMINATION
OF ASAM SERVICE LEVEL
You must address all six dimensions utilizing the information
obtained during the screen/assessment in order to
determine the appropriate ASAM service level.
NOTE: DIMENSION 4 MUST BE COMPLETED LAST – TO ENSURE THIS OCCURS DIMENSION 4 HAS BEEN MOVED TO THE END OF THE INSTRUMENT.READINESS TO CHANGE CANNOT BE ADDRESSED UNTIL INFORMATION ON ALL OTHER DIMENSIONS HAS BEEN GATHERED.
JANUARY 2018
DIMENSION 1 ACUTE INTOXICATION and/or WITHDRAWAL POTENTIAL
Dimension 1INTOXICATION Must consider type of substance(s) used
1)WHAT RISK IS ASSOCIATED WITH THE CURRENT LEVEL OF INTOXICATION?
Last Use
No substance use in the last (30) days 0
No substance use in the last (3) days 1
Substance use in the last three (3) days2
Substance use in the last twenty-four (24) hours 3
Substance use within the past twelve (12) hours 4 _____
If the response for question 1 is0 consider proceeding to Dimension 2 otherwise continue scoring
______
______
2)ARE INTOXICATION MANAGEMENT SERVICES NEEDED TO ADDRESS ACUTE
INTOXICATION?
No substance use in last thirty (30) days 0
No indication of current intoxication1
Intoxicated but, able to participate in the interview 2
Intoxicated and not coherent3
Intoxicated and unable to function 4 _____
______
______
Total of Intoxication Scores_____
Score questions 1 & 2 only
ACUTE INTOXICATION COMMENTS
______
______
Dimension 1WITHDRAWAL MANAGEMENT (WM)
3)IS THERE SIGNIFICANT RISK OF SEVERE WITHDRAWAL SYMPTOMS, SEIZURES, OR OTHER MEDICAL COMPLICATIONS BASED ON THE CONSUMER’S PREVIOUS WITHDRAWAL HISTORY?
No current risk of withdrawal indicated0 No prior WM episodes and/or related medical issues 1
Some risk of withdrawal and/or past history of WM episodes2
Immediate need of WM services with medical and/or seizure risk 3
Need of WM with medical and/or seizure risk past episodes of withdrawal4 _____
______
______
4)WHAT IS THE AMOUNT, FREQUENCY, CHRONICITY, RECENT USE OR DISCONTINUATION OR SIGNIFICANT REDUCTION IN SUBSTANCE USE? (PATTERN OF RECENT USE)
Substance use less than one time per week in the last thirty (30) days0
Substance use with no related problem behavior(s)1
Weekly substance use with obvious intoxication but no related problems 2
Daily substance use resulting in problematic and/or uncontrolled behavior 3
Substance(s) used multiple times daily resulting in significant problems 4_____
______
______
5)POTENTIATION (INTENSIFYING) EFFECT OF SUBSTANCE(S)
List all potentiating substances used
No use of potentiating substances 0
Sporadic (less than once weekly) use of potentiating substances 1
Weekly use of potentiating substances 2
Daily use of potentiating substances 3
Regular and potentially dangerous amounts of potentiating substance(s)4_____
______
______
6)ARE THERE CURRENT SIGNS OF WITHDRAWAL?
Substance use less than one time per week in the last thirty (30) days0
No indications of withdrawal 1
Some withdrawal risk or past history of WM episodes 2
Immediate need of WM services 3
Immediate need of WM services with multiple past episodes of WM4_____
______
______
Total of Withdrawal Management Scores_____
Score questions 3 through 6 only
7)IS AMBULATORY WM SAFE TO CONSIDER FOR THIS CONSUMER? YES__ NO__
8)ARE SUFFICIENT SUPPORTS FOR AMBULATORY WM PRESENT? YES__ NO__
Questions 7 and 8to be answered but, not scored
WITHDRAWAL MANAGEMENT COMMENTS
______
DIMENSION 1 ACUTE INTOXICATION
Raw scoreSeverity rating
0_____ (0) No problem
SCORINGQuestions 1& 2 only1-2_____ (1) Minimal problem
3-4_____ (2) Moderate problem
5-6_____ (3) Significant problem
7-8_____ (4) Severe problem
For a score of 2 or greater consider implementing intoxication managementservices
DIMENSION 1 WITHDRAWAL MANAGEMENT
Raw scoreSeverity rating
0_____ (0) No problem
SCORINGQuestions 3 through 6 only1-4_____ (1) Minimal problem
5-8_____ (2) Moderate problem
9-12_____ (3) Significant problem
13-16_____ (4) Severe problem
For a score of 2 or greater consider implementing withdrawal management services immediately
DIMENSION 2 BIO-MEDICAL CONDITIONS AND COMPLICATIONS
1) ARE THERE CURRENT PHYSICAL ILLNESSES OR CONDITIONS, ACUTE OR CHRONIC, OTHER THAN WITHDRAWAL? If the rating for question “1” is “0”, go to question 4, otherwise continue scoring.
No illnesses or conditions present and the consumer is functioning well 0
Any problems are manageable with ability to tolerate pain and discomfort1
Some difficulty managing physical problems and/or tolerating pain2
Limited ability to manage physical problems and/or tolerate pain3
Incapacitated due to severe medical problems and/or physical conditions 4_____
______
______
2)ARE THERE ACUTE OR CHRONIC CONDITIONS THAT REQUIRE STABILIZATION?
List all conditions reported (ACUTE i.e., infection, bone fracture, injury)
(CHRONIC i.e., chronic pain requiring painmanagement, diabetes, asthma)
No medical condition(s) are in evidence 0
Few medical problems are present with mild and managed symptoms1
Current or ongoing, non-severe illness, problem(s) or condition(s) are present2
Serious or unstable illness, problem(s) or condition(s) exist requiring attention3
Severe illness, problems or conditions likely to interfere with tx present4_____
______
______
3)IS THERE A COMMUNICABLE DISEASE PRESENT THAT COULD IMPACT THE WELL-BEING
OFOTHER CONSUMERS OR STAFF? i.e., HCV, TB, STD, influenza
No infectious disease(s) are present 0
An infectious disease is present but being treated 1
An infectious disease is present but treatment has not been initiated 2
A highly infectious disease is present with bodily fluid infection risk 3
A highly infectious disease is present with airborne infection risk4_____
______
______
4)IS THE CONSUMER PREGNANT?
The consumer is not pregnant 0
The consumer is pregnant and receiving pre-natal care 1
The consumer is pregnant but not receiving pre-natal care 2
The consumer is pregnant and experiencing complications3
The consumer is pregnant and experiencing severe complications4 _____
______
______
5)WHAT IS THE PREGNANCY HISTORY FOR THIS CONSUMER?
There have been no prior pregnancies 0
There have been prior pregnancies with no difficulty or complications1
The consumer has experienced a prior miscarriage 2
Live birth with complications 3
There have been multiple live births with complications and/or miscarriages4_____
______
______
6) HAS THE CONSUMER BEEN PRESCRIBED ANY KIND OF MEDICATIONS?
List all prescribed medications reported
There is no medication need indicated 0
The consumer is taking meds as prescribed 1
The consumer is mostly compliant with medication(s)2
The consumer is somewhat non-compliant with medication(s) 3
The consumer is regularly non-compliant regarding medication(s) 4_____
______
______
7)DOES THE CONSUMER USE NICOTINE PRODUCTS?
No nicotine products used 0
Nicotine products are used weekly or less often 1
Nicotine is used less than once daily or no more than once per day 2
Nicotine is used several times daily 3
Nicotine is used multiple times daily, often one of the first actions of the day4 _____
______
______
8)ALL MEDICAL CONDITIONS ARE STABLE WITH CONCURRENT TREATMENT
AND/OR MONITORINGYES__ NO__
Question 8 to be answered but, not scored
Total of Dimension 2 Scores_____
Score questions 1 through 7 only
DIMENSION 2 BIO-MEDICAL CONDITIONS AND COMPLICATIONS
Raw scoreSeverity rating
0 _____ (0) No problem
SCORING1-7_____ (1) Minimal problem
8-14_____ (2) Moderate problem
15-21_____ (3) Significant problem
22-28_____ (4) Severe problem
COMMENTS FOR DIMENSION 2
______
DIMENSION 3 EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS
AND COMPLICATIONS
1)ARE THERE CURRENT PSYCHIATRIC ILLNESSES OR PSYCHOLOGICAL,BEHAVIORAL, EMOTIONAL,
OR COGNITIVE CONDITIONS THAT NEED TO BE ADDRESSED BECAUSE THEY CREATE RISK OR COMPLICATE TREATMENT?
No emo/beh/cog condition(s) negatively impacting treatment exist0
Managed emo/beh/cog condition(s) not impacting treatment exist1
Emo/beh/cog condition(s) exist that minimally impact treatment2
Emo/beh/cog condition(s) negatively impacting treatment exist 3
Emo/beh/cog condition(s) that will severely impact treatment exist 4_____
______
______
2) ARE THERE CHRONIC CONDITIONS THAT REQUIRE STABILIZATION OR TREATMENT?
i.e., bipolar disorder or chronic anxiety
No chronic emo/beh/cog condition(s) are present or in the history0
Chronic but well managed and stabilized emo/beh/cog condition(s) exist1
Chronic emo/beh/cog condition(s) with some need of stabilization exist2
Chronic emo/beh/cog condition(s) needing significant stabilization exist3
Emo/beh/cog condition(s) that will severely impact treatment exist 4_____
______
______
3)DO ANY EMOTIONAL, BEHAVIORAL OR COGNITIVE CONDITIONS APPEAR TO BE PART
OF THE ADDICTIVE DISORDER, OR DO THEY APPEAR TO BE AUTONOMOUS?
No exacerbating emo/beh/cog condition(s) are present 0
Minimal and managed related emo/beh/cog condition(s) exist 1
Some related emo/beh/cog condition(s) requiring attention exist2
Related problems and/or conditions requiring significant attention exist3
Related problems and/or conditions severely impacting treatment exist4_____
______
______
RISK4)IS THE CONSUMER AT RISK FOR SELF-HARM?
DOMAINSThere is no apparent risk of self-harm0
If questions 4 The risk of self-harm is present but minimal1
and/or 5 areThere is moderate risk of self-harm that needs to be addressed 2
elevated, haltThere is significant risk of self-harm that will need to be addressed 3
interview andRisk of self-harm is high and must be addressed prior to treatment4_____
address______
immediately______
5) IS THE CONSUMER AT RISK TO HARM OTHERS?
There is no apparent risk of harm to others0
The risk of harm to others is present but minimal1
There is moderate risk of harming othersthat needs to be addressed2
There is significant risk of harming others needs to be addressed3
Risk of harm to others is high and must be addressed prior to treatment4_____
______
______
6)HOW IMPULSIVE IS THE CONSUMER?
The consumer is not impulsive 0
The consumer is minimally impulsive but manages to delay response 1
The consumer is impulsive but is usually able to delay response2
The consumer is highly impulsive and only minimally able to delay response 3
Highly impulsive with limited or no ability to filter or delay responses4_____
______
7)EVEN IF CONNECTED TO THE ADDICTION AND SUB-DIAGNOSTIC, ARE ANY EMOTIONAL,
BEHAVIORAL OR COGNITIVE SIGNS OR SYMPTOMS SEVERE ENOUGH TO WARRANT SPECIFIC
MENTAL HEALTH TREATMENT? i.e., suicidal ideation and depression due to a “methamphetamine crash”
No symptoms are present0
Minimal symptoms present that are well managed 1
Some symptoms are present that could negatively affect treatment 2
Significant symptoms with negative effect to treatment exist 3
Severe symptom set exists that must be addressed prior to SUD treatment4_____
______
8)IS THE CONSUMER ABLE TO MANAGE THE ACTIVITIES OF DAILY LIVING AND
COPE WITH ANYEMOTIONAL,BEHAVIORAL OR COGNITIVE CONDITIONS?
i.e., grooming, nutrition or shelter and or co-occurring disorders
Manages the activities of daily living well with no conditions present0
Conditions are minimal and well-managed with occasional assistance1
Conditions exist, some difficulty in managing symptoms, requires assistance2
Serious difficulty coping with existing symptoms, requires regular assistance 3
Critical impairments in coping with symptoms needing ongoing services to
manage the basic activities of daily living4_____
______
______
9)ALL EMO/BEH/COG CONDITIONS ARE STABLE WITH CONCURRENT TREATMENT
AND/OR MONITORINGYES__ NO__
Question 9 to be answered but, not scored
Total of Dimension 3 Scores_____
Score questions 1 through 8 only
DIMENSION 3 EMOTIONAL/BEHAVIORAL/COGNITIVE CONDITIONS AND COMPLICATIONS
Raw scoreSeverity rating
SCORING 0_____ (0) No problem
1-8_____ (1) Minimal problem
9-16_____ (2) Problem
17-24_____ (3) Significant problem
25-32_____ (4) Severe problem
COMMENTS FOR DIMENSION 3
______
______
NOTE: DIMENSION 4 MUST BE COMPLETED LAST – TO ENSURE THIS OCCURS DIMENSION 4 HAS BEEN MOVED TO THE END OF THE INSTRUMENT.
READINESS TO CHANGE CANNOT BE ADDRESSED UNTIL INFORMATION ON ALL OTHER DIMENSIONS HAS BEEN GATHERED.
DIMENSION 5 RELAPSE, CONTINUED USE, OR CONTINUED PROBLEM POTENTIAL
1)IS THE CONSUMER IN IMMEDIATE DANGER OF CONTINUED SEVERE MENTAL HEALTH DISTRESS AND/OR SUBSTANCE USE?
No risk of continued distress or substance use 0
Any issues related to urges to use and/or distress are well managed 1
Some issues exist creating risk as to the capability to address distress/cravings2
At risk with little ability to address distress/cravings3
At risk with no ability to address distress or halt continuing substance use4_____
______
______
2) DOES THE CONSUMER HAVE ANY RECOGNITION OR UNDERSTANDING OF, OR SKILLS IN COPING
WITH, HIS/HER ADDICTIVE OR CO-OCCURRING MENTAL HEALTHDISORDER IN ORDER TO
PREVENT RELAPSE, CONTINUED USE, OR CONTINUED PROBLEMS SUCH AS SUICIDAL BEHAVIOR?
Understanding of issues and adequate coping skills tools in place0
Some understanding of issues and tools in place for successful coping 1
Lack of understanding of issues and/or adequate tool to cope 2
No understanding of exacerbating issues and limited tools to cope 3
Lack of recognition of exacerbating issues and/or no tools to cope4_____
______
______
3)HAVE ADDICTION/ PSYCHOTROPIC MEDICATIONS ASSISTED IN RECOVERYBEFORE?
This question should respond to either of these categories of medications ever being prescribed.
Medications have not been prescribed in the past 0
Past medication use successful in assisting recovery1
Medication use successful in assisting recovery on multiple occasions 2
Medication prescribed in the past but, not taken3
Past medication use unsuccessful in assisting with recovery efforts 4_____
If medications in these categories have been prescribed then list all of them.
______
______
4)WHAT ARE THE CONSUMER’S SKILLS IN COPING WITH PROTRACTED WITHDRAWAL, CRAVINGS, OR IMPULSES?
No cravings/urges present or an adequate set of coping skills is in place 0
An adequate set of coping skills are regularly utilized for infrequent cravings 1
Functional in early recovery but, some coping skills are lacking 2
Inadequate skill set for early recovery, major problems with stability3
Unable to cope with withdrawal, craving(s), or impulse(s)4_____
List all substances
______
______
5)HOW WELL CAN CONSUMER COPE WITH NEGATIVE EFFECTS, PEER PRESSURE, AND STRESS WITHOUT RECURRANCE OF ADDICTIVE THINKING AND BEHAVIOR?
No problems related to coping with stressors 0
Fully able to cope with stressors and/or stressors are minimal 1
Usually able to cope with stressors but, can return to relapse thinking 2
Often unable to cope with stressors, or returns to relapse thinking3
Completely unable to cope with stressors, and usually in relapse thinking4_____
______
______
6)HOW SEVERE ARE THE PROBLEMS AND FURTHER DISTRESS THAT MAY CONTINUE
OR REAPPEAR IF THE CONSUMER IS NOT SUCCESSFULLY ENGAGED IN TREATMENT AND
CONTINUES TO USE, OR HAVE MENTAL HEALTH DIFFICULTIES?
No problems or distress are present for this consumer 0
Problem severity and risk are low, successfully engaged in treatment/recovery1
Problem reappear at times, risk moderate but, generally under control 2
Problem severity risk are high, if the consumer is not engaged in treatment3
Problem severity and risk high and unmanageable for the consumer4_____
______
______
7)HOW AWARE IS THE CONSUMER OF RELAPSE TRIGGERS AND SKILLS TO CONTROL ADDICTION IMPULSES OR IMPULSES TO HARM SELF OR OTHERS?
High awareness with low relapse risk and good coping skills in place 0
High awareness, low risk, fair level of relapse prevention/coping skills in place1
Impaired recognition/understanding of relapse issues and some problems
exist however, with prompting, self-management possible and occurs 2
Very few coping skills to interrupt addictive use or to limit relapse exist3
No coping skills to interrupt addiction or prevent/limit relapse exist 4_____
______
______
8)WHAT IS THE CONSUMERS LOCUS OF CONTROL AND LEVEL OF SELF-EFFICACY?
Strong internal locus of control and high self-efficacy in place 0
Adequate internal locus of control, high self-efficacy, with minimal issues1
Minimal awareness of internal locus of control & low self-efficacy2
Perceived external locus of control and low self-efficacy3
Compromised locus of control and very low self-efficacy 4_____
______
______
9)WHAT IS THE CONSUMERS EXPERIENCE WITH CRAVINGS AND URGES TO USE?
No cravings or urges to use have been present for some time 0
Infrequent and manageable cravings or urges to use exist1
Intermittent cravings and urges to use exist but, are usually manageable 2
Frequent cravings and urges to use exist that are usually unmanageable3
Constant and unmanageable cravings and urges to useare present4_____
List all substances
______
______
10)WHAT IS THE CONSUMERS RECOVERY ENVIRONMENT?
Strong, supportive overall recovery environment promoting success exist0
Adequate, supportive overall recovery environment 1
Some issues related to parts of the recovery environment2
Major issues and problems with the recovery environment3
The environment is completely inadequate for recovery 4_____
______
______
Total of Dimension 5 Scores_____
DIMENSION 5 RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIAL
Raw scoreSeverity rating
SCORING 0_____(0) No problem
1-10_____(1) Minimal problem
11-20_____(2) Problem
21-30_____(3) Significant problem
31-40_____(4) Severe problem
COMMENTS:
______
______
DIMENSION 6 RECOVERY/LIVING ENVIRONMENT
1) DO ANY FAMILY MEMBERS, SIGNIFICANT OTHERS, LIVING SITUATIONS OR SCHOOL OR
WORK SITUATIONS POSE A THREAT TO THE CONSUMER’S SAFETY OR ENGAGEMENT IN
TREATMENT?
The environment is highly supportive with good supports in place 0
Environment offers passive supports and consumer is successful1
Environment is not supportive of recovery but, with structure and support,
the consumer is generally able to cope2
Environment not supportive of recovery, coping is difficult with environment3
Environment actively toxic to recovery4_____
______
______
2)DOES THE CONSUMER HAVE SUPPORTIVE FRIENDSHIPS THAT CAN INCREASE RECOVERY?
Multiple supportive friendships, highly supportive of recovery exist0
Some supportive friendships exist that enhance recovery efforts 1
Friends only partially support recovery, consumer usually manages 2
No support of recovery efforts by friends3
Friends actively oppositional to recovery efforts 4_____
______
______
3)DOES THE CONSUMER HAVE FINANCIAL RESOURCES THAT CAN INCREASE RECOVERY?
Significant financial resources exist to support recovery efforts 0
Some financial resources supporting recovery exist1
Financial resources are limited or only partially support recovery efforts2
Financial resources are insufficient to support recovery efforts 3
Financial problems are an impediment to recovery efforts 4_____
______
______
4)DOES THE CONSUMER HAVE EDUCATIONAL OR VOCATIONAL RESOURCES THAT INCREASE
RECOVERY?
Significant Voc/Ed resources fully supportive of recovery exist 0
Some Voc/Ed resources exist that are supportive of recovery 1
Voc/Ed resources can only partially support recovery efforts 2
Voc/Ed resources to support recovery do not exist 3
Voc/Ed problems and limitations are an impediment to recovery 4_____
______
______
5)ARE THERE LEGAL, VOCATIONAL, REGULATORY (i.e., PROFESSIONAL LICENSURE),
CRIMINAL JUSTICE OR SOCIAL SERVICE MANDATES THAT MAY ENHANCE THE CONSUMER’S MOTIVATION FOR ENGAGEMENT IN TREATMENT?
Leg/Reg/Voc/SS issues exist that are highly supportive of recovery 0
Leg/Reg/Voc/SS issues exist that generally support recovery 1
Minimal or no Leg/Reg/Voc/SS issues exist supportive of recovery 2
Some Leg/Reg/Voc/SS issues exist that discourage or inhibit recovery 3
Legal/Reg/Voc/SS issues exist that interfere with recovery efforts 4_____
______
______
6)ARE THERE TRANSPORTATION ISSUES THAT NEED TO BE ADDRESSED?
Significant transportation exists to support recovery 0
Transportation to support recovery is usually available 1
Transportation to support recovery is sometimes available 2
Transportation is not available to support recovery 3
Transportation is not available and distances are prohibitive 4_____
______
______
7)ARE THERE CHILD CARE ISSUES THAT NEED TO BE ADDRESSED?
Child care is fully accessible with no issues or problems or no children 0